Atlas of Primary Care Procedures, 1st Edition

Ear, Nose, and Throat Procedures

57

Cerumen Impaction Removal

Cerumen (earwax) is a natural product of the external auditory canal. The exact function of cerumen is unknown. It usually occurs as a sticky, honey-colored wax that can darken with oxidation. Sometimes, however, the cerumen may become hard and scaly. Accumulation of cerumen can result in hearing loss, tinnitus, otalgia, vertigo, and infection.

The two common techniques for removal of impacted cerumen are with an ear curette or with irrigation. The ear curette method is most effective for small amounts of easily visible wax. Irrigation usually takes longer and is messier than the curette technique, but it rarely fails. It is often required for dense or large circumferential cerumen impactions and when the curette technique has failed or caused pain. Suction also may be used for very soft cerumen but is rarely adequate for complete removal of an impaction.

A cerumen-softening agent such as triethanolamine (Cerumenex), carbamide peroxide (Debrox), or cresyl acetate (Cresylate) may be used to soften or melt cerumen. These agents may be applied at home for 3 days before a visit for impaction removal. In studies, water has surprisingly proved to be an effective softening agent, whereas olive oil appears to be almost totally ineffective as a wax dispersant. Docusate sodium solution (Colace) may be instilled intra-aurally for 15 minutes and the ear irrigated.

Tympanic membrane perforation and damage to ossicles constitute the most serious potential complication, because they can lead to hearing loss. Patients may experience pain, vertigo, nausea, or vomiting during the procedure. Minor canal wall abrasions and bleeding may occur, especially if hard adherent wax is removed by mechanical means. Rarely, otitis externa and idiopathic tinnitus may occur.

Among alternative methods, ear candles are the most popular method of cerumen removal. A hollow candle is burned on one end, with the other end in the ear canal; the intent is to create negative pressure and draw cerumen from the ear. Unfortunately, studies show that ear candles do not produce negative pressure in the ear and do not remove cerumen from the external auditory canal. Candle wax has been deposited in some ears, and a survey of otolaryngologists identified ear injuries resulting from ear candle use. Instilling oil in the ear has been found to be minimally helpful, but not as effective as easily available over-the-counter and prescription products.

P.464

After cerumen removal, instruct the patient to return if increasing pain, decreased hearing, vertigo, or purulent drainage develops in the treated ear. Consider educating the patient about periodic ear cleaning using commercially available earwax softeners and a squeeze bulb. Also inform the patient that the curved anatomy of the ear canal makes self-instrumentation of the ear canal with cotton-tipped applicators or other wax removal tools unlikely to help, likely to make accumulations worse, and dangerous to the delicate hearing apparatus of the ear.

INDICATIONS

  • Otalgia
  • Decreased hearing on the affected side
  • Obscured visualization of the tympanic membrane
  • External otitis associated with cerumen

CONTRAINDICATIONS

  • Clinician unfamiliarity with the equipment
  • Clinician's unfamiliarity with the anatomy of the external auditory canal
  • Distorted or abnormal anatomy
  • Previous scarring
  • Known or suspected cholesteatoma (refer to an otolaryngologist)
  • The affected ear is the only hearing ear (consider referral to an otolaryngologist)
  • For irrigation because of known or suspected perforation of the tympanic membrane

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PROCEDURE

Position the patient in a sitting position on a chair or examination table. Allow children to sit in a parent's lap or lie on the examination table with a parent or assistant stabilizing the head. Apply posterior traction on the helix as necessary to visualize the ear canal and any impacted cerumen using an operating otoscope.

 

(1) Have patient sit on a chair or examination table, and apply posterior traction on the helix as necessary to visualize the ear canal and any impacted cerumen.

Select a curette or ear loop that easily fits the canal. Gently remove the impacted cerumen by taking small top-to-bottom scoops with minimal forward pressure. This can be done through the otoscope or by direct visualization after carefully examining the canal and cerumen with the scope.

 

(2) Using a curette or ear loop, gently remove the impacted cerumen by taking small top-to-bottom scoops with minimal forward pressure.

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If hardened cerumen is encountered, the same motion may be used to “roll” and pull apart the ball or extract it in toto. Alternatively, if hardened cerumen is encountered, instill mineral oil, 3% hydrogen peroxide, or a commercially available wax softener such as Cerumenex or Debrox for 5 to 10 minutes to soften the cerumen and facilitate removal.

 

(3) If hardened cerumen is encountered, the same motion can be used to “roll” and pull apart the ball or extract it in toto.

PITFALL: Vigorous removal can be traumatic. Consider prescribing topical otic antibiotics if the canal epithelium is disrupted or bleeding is present.

PITFALL: If the cerumen is adherent to the tympanic membrane, irrigation or suction may be necessary for atraumatic removal.

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Several devices for irrigating an ear are shown: a 20- to 50-mL syringe with a large-bore Angiocath attached (Figure 4A), a 20- to 50-mL syringe with attached butterfly tubing with needle cut off (Figure 4B), and a metal irrigator syringe (Figure 4C). Fill the syringe with body-temperature (37C) water or normal saline. Alternatively, a jet irrigator adjusted to its lowest pressure setting may be used.

 

(4) Devices for irrigating an ear: a 20- to 50-mL syringe with a large-bore Angiocath attached, a 20- to 50-mL syringe with attached butterfly tubing with the needle cut off, and a metal irrigation syringe.

PITFALL: Using water that is too warm or cold increases the risk of stimulation of the vestibular reflex and associated nystagmus and nausea.

PITFALL: Using a jet irrigator on any but the lowest setting increases the risk of perforation of the tympanic membrane.

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Place a gown or towel on the patient. Place an ear basin under the affected ear and have the patient tilt his or her head slightly to that side.

 

(5) Place a towel on the patient, place an ear basin under the affected ear, and have the patient tilt his or her head slightly to that side.

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Direct the water jet toward the superior part of the impaction to allow space for the outflow of water and cerumen. After cerumen washes out of the canal, reexamine to determine if any impacted cerumen remains. Repeat the process until the canal is clear. Remove the apparatus and drapes, and dry the ear. Rarely, very hard impacted cerumen does not clear after several minutes of irrigation. If this occurs, terminate the procedure, and initiate the use of a liquid earwax softener. Have the patient return in a few days for cerumen removal.

 

(6) Direct the water jet toward the superior part of the impaction to allow space for the outflow of water and cerumen.

PITFALL: Avoid direct irrigation on the tympanic membrane that can cause pain, nausea, or perforation.

PITFALL: Prescribe topical otic antibiotics if canal epithelium is disrupted or bleeding is present.

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CODING INFORMATION

 

CPT® Code

Description

2002 Average 50th Percentile Fee

 

69210

Removal impacted cerumen (separate procedure), one or both ears

$57

 

CPT® is a trademark of the American Medical Association.

INSTRUMENT AND MATERIALS ORDERING

Operating otoscopes, ear curettes, emesis or ear basin, ear syringes, and commercially available jet irrigators (Water-Pik) can be obtained from http://www.AllHeart.com-Professional Appearances, Inc., 431 Calle San Pablo, Camarillo, CA 93012 (fax: 805-445-8816;http://www.store.yahoo.com/allheart/index.html) and from MD Depot; 7590 Commerce Court; Sarasota, FL 34243 (phone: 888-355-2606; fax: 800-359-8807; http://www.mddepot.com).

Cerumen-softening agents such as mineral oil, triethanolamine (Cerumenex), carbamide peroxide (Debrox), or cresyl acetate (Cresylate) may be obtained from pharmacies.

BIBLIOGRAPHY

Andaz C, Whittet HB. An in vitro study to determine efficacy of different wax-dispersing agents. ORL J Otorhinolaryngol Relat Spec1993;55:97–99.

Blake P, Matthews R, Hornibrook J. When not to syringe an ear. N Z Med J 1998;111:422–424.

Carr MM, Smith RL. Ceruminolytic efficacy in adults versus children. J Otolaryngol 2001;30:154–156.

Dinsdale RC, Roland PS, Manning SC, et al. Catastrophic otologic injury from oral jet irrigation of the external auditory canal.Laryngoscope 1991;101(Pt 1):75–78.

Eekhof JA, de Bock GH, Le Cessie S, et al. A quasi-randomised controlled trial of water as a quick softening agent of persistent earwax in general practice. Br J Gen Pract 2001;51:635–537.

Grossan M. Cerumen removal—current challenges. Ear Nose Throat J 1998;77:541–546, 548.

Grossan M. Safe, effective techniques for cerumen removal. Geriatrics 2000;55:80, 83–86.

Macknin ML, Talo H, Medendrop SV. Effect of cotton-tipped swab use on ear-wax occlusion. Clin Pediatr 1994;33:14–18.

Masterson E, Seaton TL. How does liquid docusate sodium (Colace) compare with triethanolamine polypeptide as a ceruminolytic for acute earwax removal? J Fam Pract 2000;49:1076.

Seely DR, Quigley SM, Langman AW. Ear candles—efficacy and safety. Laryngoscope 1996;106:1226-001229.

Singer AJ, Sauris E, Viccellio AW. Ceruminolytic effects of docusate sodium: a randomized, controlled trial. Ann Emerg Med 2000;36:228–232.

Wilson PL, Roeser RJ. Cerumen management: professional issues and techniques. J Am Acad Audiol 1997;8:421–430.